What's the biggest mistake you've ever made as a nurse? What did you learn from it? - page 5

If you feel comfortable posting to this thread, awesome. If not, no biggy! I was wondering what the biggest mistake you've ever made in your nursing career has been. It could have to do with drug... Read More

  1. by   nkochrn
    I took care of a family member, actually my husband's family member. Not taking care of family isn't always an option in a small rural hospital, but I try to avoid it as much as possible, since having to call my FIL and tell him his brother died!
  2. by   nurseprnRN
    I've posted this before-- there's a whole thread on errors new grad make. Still scares me to think about.

    [FONT=comic sans ms]the worst thing that happened to me as a new grad was the day i got a lady with fresh postop carotid endarterectomy whose bp was too high. the chief of surgery was right there and told the intern (what we now call an r1) to give a medication called apresoline iv push stat to drop her pressure to safer levels, to avoid rupturing her carotid, and to repeat it q5minutes until her pressure was under control. it wasn't a familiar medication to me, but i figured the chief of surgery oughta know so i went and got it out of the drawer and gave the first dose, the intern at my side. five minutes later, pressure is still too high. intern says, give it again, so i did. same thing five minutes after that. and at twenty minutes.
    [FONT=comic sans ms]and then her bp went down. and down. and down, and down, and down, and the woman who was awake and talking to us after her elective endarterectomy drowsed off and went to sleep. and she never woke up again, because we dropped her bp so far she stroked out.
    [FONT=comic sans ms]chief of surgery denied ever having said any such thing [FONT=comic sans ms] and hung the intern out to dry, which was devastating to him. i was finally able to go look it up and learned that the peak effect of iv apresoline can be 30 minutes after the dose[FONT=comic sans ms], so of course we gave her waaaaayy too much. i was devastated.
    [FONT=comic sans ms]moral of the story was that i learned never to give anything, even in an emergency, that i didn't know about. if i had no time to look it up, i would hand it to the md or someone else to give. of course, in time i knew all the emergency drugs, and that became a moot point, but still.
    [FONT=comic sans ms]sometimes i still see that woman in my dreams, and it's been almost, good grief, forty years.
  3. by   whichone'spink
    I am a new nurse, so I know this mistake will not be my only one. But now I'm more attentive about patient safety because of it. I had a lady who came for an intractable migraine status post concussion from a fall. I gave her a migraine cocktail of Benadryl, toradol and Thorazine. I actually made two mistakes really. First, I hooked up the Thorazine as a piggyback, and set the rate higher than it should have been. It should have been a secondary on a pump. Second thing I didn't do was put her back on the monitor. She'd just come back from the bathroom, and was not on the monitor. This all happened at change of shift. When the night shift nurse went in, the patient was completely snowed and her o2 sats were very low. She well could have gone into respiratory arrest if the night shift nurse didn't go in any sooner. Her sats improved with oxygen and she eventually woke up some more. Thank God it wasn't worse. Moral of the story: Maintain situational awareness at all times, especially with regard to patient safety. Especially after giving a medication that reduces respiratory drive.
  4. by   Not_A_Hat_Person
    My first big nursing mistake was taking a job at the Nursing Home from Hell, despite warnings from colleagues who had worked there, because they were offering a substantial pay raise. We needed the money, and I'd worked in toxic environments before (though not in nursing), so I thought I could handle it. After 2-1/2 days of training I was on my own with 15 high-maintenance patients, LNAs who only did ADLs and feeding, and no help. I lasted 6 weeks.

    My next mistake was taking a job at the facility I'd just left. I was in a different building, with some of the same problems, plus a bunch of others. Among other things, I was the only person on my shift who didn't smoke. If anything happened, I had to respond because I was the only one in the building. My boss yelled at me for questioning a morphine dose that turned out to be very wrong.

    One night, they needed overnight coverage. I was still finding my way around the building. I didn't even know how to lock and unlock the doors. However, I'd been out of work, my husband needed surgery (which kept him out of work for 10 weeks), and we needed heating oil. I was desperate, so I volunteered for the shift. I had 60 patients and 1 LNA. I screwed things up very badly. I was already on thin ice at that facility, and that was the last straw. I was suspended, then fired.

    I've had 2 jobs since then. Both were pay cuts, but working conditions were much better.

    I've learned that money isn't everything. And I will never work LTC again.
    Last edit by Not_A_Hat_Person on Jan 31, '13
  5. by   RNewbie
    Quote from Not_A_Hat_Person
    I had 60 patients and 1 LNA.
    what? how is this legal, and how are you the one who got in trouble?
  6. by   patriece1991
    I am in my last semester of nursing school...while I have had a few opportunities to do IV's, not all of my classmates have. They taught us in simulation but many have not had the chance to do it in an actual clinical setting, on a patient. It is nothing against the nursing program, its just dependent upon the learning opportunities that arise during your clinical times and the type of floor you are placed on. Good luck in your program!
    : )
  7. by   uRNmyway
    Quote from rita359
    You'd be surprised at some of the things new nurses come out of school and have never done.

    My advise is , whenever in clinicals, be sure nurses know you want to at least watch anything interesting even if you can't talk your instructor into letting you do it.
    I did that in all the clinical settings I went to. I told the nurses if they had something they thought I should see and learn, to please let me know! My teachers were also aware that I wanted to see as much as I could.
    I later used that when I was an RN and knew students would be coming around that day. I worked until 8am, they came in at 7am. So I made sure to keep blood work until they came around and asked them if any of them wanted to do it. The teachers loved it, and the students loved even more that I volunteered to go with them instead of their teacher, since I knew how much it would stress me out to have them breathing down my neck doing new skills...
  8. by   HyperSaurus, RN
    2nd day on orientation, I was orienting with one of the LPNs. We were hanging a lasix drip, which was not programmed in our alaris pump library. The label wasn't very clear on the rate,--we ended up giving the entire bag in one hour. Luckily, no harm came to patient. It was an awful feeling though, when I figured out what happened.
    Lesson: if confused, check EMAR again or call pharmacy! Also, I am now VERY compliant with med scanning. Many people on our floor tend to scan pt labels outside the room, and sign out meds that way--usually because our WOWs (laptop) have very poor battery life or they don't want to wait for the new wired in computers to load up. Now I just suck it up and wait for the computer.
  9. by   Laboratorian
    Quote from sharpeimom
    [FONT=comic sans ms]never try to have a conversation with a 400#+ h*ll's angel pt. alone. i am 5'4" and weighed [FONT=comic sans ms]about 110#, and was absolutely no match at all. he grabbed me and suddenly i was airborne. [FONT=comic sans ms]he yelled "make a wish, b*tch! he had grabbed me by my right shoulder and left hip.
  10. by   mariebailey
    I administered Rocephin to a patient with gonorrhea, and I had not twisted the needle tightly enough on the syringe. Thus , medicine leaked out when I administered it. The doctor said the patient would have to abstain from sex & return for re-testing in 4 weeks as a consequence. I flagged her chart so I could make sure she returned. I called & called, but she never returned. If there was a slight bump in gonorrhea rates in my community during that time frame, you're welcome!
  11. by   LadyFree28
    The mistakes that stand out for me:

    1. Giving a different concentration of a low-molecular weight heparin to a pt; right med, wrong dose...was on orientation for a week, new preceptor...first incident report as a nurse. Told the pt immediately, was super cool about it, doc was too, pt survived.

    2. Gave pt med AFTER another nurse gave the dose of medicine. Assignment was changed. That nurse was very ineffective at communication, teamwork, and was known to be unsafe...medical debris easily accessible to the children...literally rushing around to make sure kids did not have access to being injured, infusing incorrect feeds to the wrong pts. Job has ONLY paper charting, no high tech fail safes. Instituted a LOT of policies because of a lot of issues with this nurse. FINALLY got fired after her almost 4 years of "service" to our pediatric facility. Still makes me hyper vigilant to check and trust my gut judgement, and literally harass people and continue to check the assignment throughout the day for any "surprises"... :-/

    A LOT of near misses in between and after the last incident, even in declining or emergency situations. I just try to remain as safe as possible...
  12. by   Nugget
    Mine happened just last night! Hence the reason I searched "mistakes" on here as soon as I came home, crying.
    These happened with the same patient:
    1. Patient had order for lorazepam 1-2 mg IV for seizures. I read the order as IM and gave as such. Realized that this morning, and also realized that I wouldn't have been able to give it IV anyway, because I am not a critical care RN. Called the MD on-call who was unphased and said "Oh, okay! Whatever" haha.

    2. Also this morning, realized my patient's foley cath output was ohhhh about 100mL overnight, and I was so preoccupied with the 1 million other tubes coming out of her, I didn't even realize.

    I actually want to quit and hide in a hole. 1st year of nursing is sucking.
  13. by   PRNketamine
    I infused an entire unit of platelets on a little girl in under an hour. One of the clamps that should have been closed (the clamp running from the bag to the syringe) wasn't fully closed. So while the platelets were running from the syringe pump they were also running by gravity. Luckily nothing happened.